What's Next for U.S. Healthcare?

The Health Policy Program’s December 17 event, titled “What’s Next for US Healthcare,” brought together some of the most important thought leaders in modern health policy for a discussion that reached beyond the ideas policymakers have already debated to death, and began looking at solutions to the treatment delivery system challenges that are coming in the wake of the Affordable Care Act (ACA). Here are some of the event highlights from Health Policy Program Research Associate Joe Colucci :

* Shannon Brownlee, director of New America’s Health Policy Program, kicked off the event by addressing the possibility of an imminent hospital debt crisis. Hospitals are heavily in debt from expanding capacity, and now they're facing revenue pressure from a variety of sources. The federal government seems to be considering cuts in Medicare payments, private employers like Wal-Mart are becoming involved in getting their employees low-cost care at a few top-quality hospitals, and care improvement efforts are starting to focus on keeping very sick people out of the hospital as much as possible. All of those factors add up to lower hospital revenues. If hospitals can’t become more efficient, some will have to get smaller, or may even default on their debts. But if we wait for that to happen on its own, those failures could to have major negative economic effects, both in local communities and in financial markets. We should be thinking about ways to help the hospital system adjust—and that may mean something like a hospital closing commission modeled after the base closing commission, which identified unneeded military bases to close in order to save money.

* Next, Dr. Marty Makary, surgeon at Johns Hopkins and author of Unaccountable,spoke of the problems created by medicine’s “closed-door” culture. While policymakers have often looked to patients to “make better choices” in terms of their treatment, patients have often been denied the information about quality of care they would need to make those choices. While there were once some genuine reasons to think releasing data on patient outcomes for particular physicians would unfairly disadvantage doctors who treated especially complex patients, quality measurement methods have gotten much better in recent years. Makary argued that it's time to give patients access to information on doctors’ and hospitals’ rates of bad outcomes like deaths and infections. Maybe if we do that, competition between hospitals will move beyond “parking and valet amenities” to being based on the quality of care.

* Representative Jim Cooper of Tennessee connected these issues to the policy world with a simple message: “To save Medicare and Social Security, you must be for reform.” Improving care by giving patients better information and making hospitals more efficient is a crucial part of that reform, and it fits in well with pieces of the Affordable Care Act like the Independent Medicare Advisory Board (IPAB), the Patient-Centered Outcomes Research Institute (PCORI), and the tax on expensive insurance plans. Those are key cost control pieces of the healthcare law that will either help hospitals eliminate waste or help patients make more cost-effective choices. Cooper also presented a few ideas that might be considered “out there” in the current climate, but are the kind of creative ideas that could save a lot of money. Those include: A new federal program for expensive dual-eligible (Medicare & Medicaid) patients, changes in our lifestyles to reduce the burden of illness, and giving doctors more legal and professional latitude to say “no” when there are no good treatment options.

* Dr. Vikas Saini of the Lown Institute tied the idea of greater hospital efficiency to a renewal of the doctor-patient relationship, and placing more emphasis on getting patients off the “assembly line” and into meaningful interactions with clinicians. While conversations with patients can take more time than just running them through the checklist of procedures and tests, it’s usually far more valuable and less costly in the long run. One way we might encourage hospitals to improve care and incentivize improving health over just providing procedures is by making Accountable Care Organizations (ACOs—provider groups that get paid by Medicare to reduce spending on their patient population) or local hospitals responsible not just for the people who walk through their doors, but for the health of the entire local community.

* Finally, Dr. Kavita Patel of the Brookings Institution brought some of the ideas together and tried to link them to the changes coming in the near future. She noted that while “innovations in care” and “accountable care” are horribly overused phrases, ACOs are still one of the most important delivery system changes included in the ACA, and we need to do everything possible in order to ensure they work. Changing how physicians get paid will be a critical part of that work—fortunately, medical students are more open than ever to working as salaried employees.